Intake Assessment Valant Final
Treatment Approach [checkbox name="variable_1" value="Dialectical behavior therapy to learn new skills to address behaviors and emotions that have been identified as causing problems in life;Person centered therapy approaches including providing unconditional positive regard, empathetic understanding, and genuineness|Cognitive Behavioral Therapy for the exploration of patterns of certain thoughts, feelings and behaviors;Person centered therapy approaches including providing unconditional positive regard, empathetic understanding, and genuineness|Cognitive processing Theory to help client learn how to modify and challenge unhelpful beliefs related to the trauma; Cognitive Theory to assist client with modifying the pessimistic evaluations and memories of trauma, with the goal of interrupting the disturbing behavioral and/or thought patterns that have been interfering in daily life"] Identifying Information: [text name="name" memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"], [checkbox value="single|married|partnered"] [checkbox value="cis-gender female|cis-gender male|transgender female|transgender male|gender non-binary individual"][text memo="other gender" value="20"] who [select value="lives with their significant other|lives with their family|lives alone|is homeless|lives with their parents|lives with their children|lives with a roommate|lives in a grouphome|"][text size="20"] in [text memo="residing location" size="20"]. [select value="They are their own guardian|They have a DHS guardian |Their guardian is |"][text memo="guardian" size="20"]. [textarea memo="Additional presentation information" rows="5"] *Chief Complaint* Date and Time of Service:[date default="today"] [text size="8"] is seen in this intake for [checkbox value="depression|anxiety|psychosis|substance abuse|cognitive impairment|impulsivity|mood lability|sleep disturbance|alcohol dependence|opiate dependence|autism spectrum disorder"] [textarea memo="other" default="" rows="1"] [textarea memo="quotes" default="" rows="1"] *Interval History* presents as [comment memo="SYMPTOM"][checkbox value="depressed|anxious|aggressive|impulsive|inattentive|irritable|withdrawn|unable to sleep|delusional|auditory hallucinations|visual hallucinations"] [textarea memo="other" default="" rows="1"] Which is described as[comment memo="SEVERITY "][checkbox value=" the same as it has been| better| somewhat worse than it has been| significantly worse than it has been"] [textarea memo="other" default="" rows="1"] notices that it is sometimes improved by [comment memo="Modifying factors "][checkbox value="talking to someone|being alone|doing something physical like walking|doing something that is distracting"] [textarea memo="other" default="" rows="1"] History of Presenting Illness: [textarea rows="6"] Current Psychiatric Medications: [textarea rows="4"] Current Suicidal Ideation: [select value="denied|yes with no plan|yes with a plan|not suicide but thoughts of being better off dead"][checkbox value="contracts for safety|cannot contract for safety"] [textarea rows="1"] [textarea name="variable_1" default="Insert Protective Factors if si"] Current Substance Use: [select value="Denied|Reports positive for "][checkbox value="alcohol|tobacco|cannabis|opiate use|methamphetamine use"] [textarea rows="1"] identifies the following symptoms: [comment memo="Pertinent System "][checkbox value="irritability|mood instability|heightened anxiety|attention problems|troubled by hallucinations|fearfulness|nightmares|alcohol cravings|opiate cravings"] [textarea memo="other" default="" rows="1"] Other systems: Neurological - [checkbox value="Headaches|weakness|disturbed sleep|denied"] [textarea memo="other" default="" rows="1"] GI - [checkbox value="Upset stomach|nausea|constipation|heartburn|denied"] [textarea memo="other" default="" rows="1"]. Social Supports: [checkbox value="none|significant other|extended family|children|friends|church members"] Works: [select value="on disability|retired|unemployed|works as a |"][textarea rows="1"] Financial Concerns: [select value="none|related to healthcare costs|related to supporting family|"][textarea rows="1"] Source of Income: [select value="disability|social security|unemployment|work|family support|"][textarea rows="1"] Housing Concerns: [select value="none|unstable housing situation related to |"][textarea rows="1"] Spirituality: [select value="Christian|Catholic|Muslim|Jewish|Spiritual but not practicing|Athiest|Agnostic|"] Sexual Orientation: [select value="heterosexual|homosexual|bisexual|declined to answer|unable to assess due to symptomatic presentation|"] Military: [select value="denied|retired |active |"][textarea rows="1"] Legal Concerns: [select value="denied|"][textarea rows="1"] HISTORIES: [comment memo="All Information below is historical and not to be counted as part of the progress note"] Previous Psychiatric Medications: [textarea rows="1"] Previous Psychiatric Hospitalization (s): [select value="none|"][textarea rows="1"] Previous Therapy: Family History of Substance Use or Psychiatric Illness: History of Suicide Attempt (s): Family History of Suicide Attempt (s) or Completed Suicide: [textarea name="variable_1" default="sample text"] Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and assessed reason for treatment, current struggles and symptoms.
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